Practice Changes I Hope You Make

Transcription

1 Is that Bad? What PCPs (& Parents) Need to Know about Fractures Aharon Z. Gladstein, MD Pediatric Orthopaedics & Sports Medicine Texas Children s Hospital Assistant Professor, Orthopaedics Baylor College of Medicine Practice Changes I Hope You Make 1. X-ray entire bone and adjacent joints 2. Refer fractures needing surgery to pediatric orthopaedists/ a children s hospital 3. Consider managing selected fractures in your office 1

2 Common FOOSH Fractures Image entire bone and adjacent joints Can get both wrist and elbow fractures at same time Children Under 10 Years Rarely Get Sprains Ligaments usually attached to epiphysis on at least one side of joint Virtually as strong as those in adults Excessive force usually results in fracture 2

3 Failure to make diagnosis Failure to promptly recognize complications Failure to communicate adequately with parents Case # 1 Julia Julia is 10 years old. Her mom calls and says, Julia just fell off the balance beam at gymnastics practice and hurt her elbow. What should I do? What should you tell her? 3

4 You Tell Mom a) Put some ice on it and see how it is tomorrow b) Come to the office for examination and possible X-rays c) Go to the closest urgent care/emergency room d) Go to a children s hospital emergency room What Questions Might You Ask Before Making Recommendations? How much pain is she in? What does the elbow look like? Can she move her elbow on her own? Can she move her fingers? 4

5 Suspect Possible Fracture Pain Swelling Loss of function Beware Delays in Seeking Treatment Could be tip off to non-accidental nature Make sure story is consistent 5

6 Evaluation of Possible Fracture Kneel down Child on parent s lap Encourage active motion Inspect and palpate opposite extremity first Palpate area of concern last Neurovascular check Who Needs X-rays? Obvious deformity? Loss of function? Still hurts next day? Every bump and bruise? Yes Yes Yes No 6

7 Radiographic Evaluation Get perpendicular views of entire bone and adjacent joints Comparison Views Weigh risk and cost vs. benefit Sometimes helpful at elbow Try to review initial images with someone else before ordering them 7

8 Referring a Child with a Fracture Try to keep NPO if reduction or surgery may be needed Try to send copies of X-ray films (or CD), not just report Local ER vs. children s hospital Fractures Needing Emergent Referral Open fractures Abnormal neurovascular findings Severely displaced fractures tenting skin 8

9 Where to Refer? Urgent care center Local hospital emergency room Children s hospital emergency room Where to Refer Considerations Convenience: proximity, waiting time Facilities: child friendly (attitude, resourcesimaging, soft goods) Personnel Knowledge of and experience with children Pediatric injury assessment exam and imaging Pediatric injury management splinting, sedation 9

10 Emergency Room Julia is initially seen in the local hospital ER Found to have an elbow dislocation with an intra-articular fragment Transferred that night to a children s hospital for care Surgery Surgery for her broken elbow at the children s hospital the next morning Sent home that evening in a cast 10

11 2AM Julia s Mom Calls Julia won t stop crying. I ve given her the dose of pain medicine her doctor said to take. I can t reach her orthopaedic surgeon. What should I do? What Should You Tell Mom? a) Give Julia a bigger dose of her pain medicine b) Add a second over the counter pain medication such as ibuprofen c) Go to the nearest urgent care/emergency room d) Go back to the children s hospital ER 11

12 What questions might you ask mom before making your recommendation? Can she move her fingers? Can she straighten them out all the way? What color is her hand compared with the other one? Does her hand look swollen? Does she cry more if you try to straighten her fingers out? 12

13 Failure to make diagnosis Failure to promptly recognize complications Failure to communicate adequately with parents Compartment Syndrome Compartment: anatomic space of limited volume Extremity Compartments Swelling or edema leads Forearm Hand to increased pressure Leg Foot Increased pressure Thigh reduces perfusion Ischemic tissue swells 13

14 Compartment Syndrome Tight splint or cast can convert injured limb into a compartment! Treatment is immediate surgical decompression Six hours of warm ischemia = dead muscle Compartment Syndrome: What to Look For Severe pain on passive stretch Firm feeling of region on palpation not accurate May still have distal pulses and capillary refill 14

15 Increasing Pain in Cast Don t wait until morning If in doubt, have someone bivalve or remove cast Can always re-reduce fracture later Other Less Dangerous Cast Problems Cast Is Cracked or Broken Is the child comfortable? If yes, then wrap it with duct tape (!) and come in the next morning 15

16 Failure to make diagnosis Failure to promptly recognize complications Failure to communicate adequately with parents Case #2 Dmytro After the doctor took the cast off Dmytro s arm, it s still crooked. I can t believe he left it like that. 16

17 Fracture Remodeling Best in plane of motion Better when fracture close to joint Better in younger children Fracture Remodeling 17

18 Case #3 Zikrullah The orthopaedic surgeon didn t even put Zikrullah s broken leg in a cast, just a boot with Velcro. You could have done that yourself and then I wouldn t have had to take another morning off from work. What s with that? Unique Fractures in Children Incomplete Fractures Plastic deformation (bend) Torus (buckle) fracture Greenstick (incomplete) fracture 18

19 Toddler s Fracture Variable tenderness and swelling Inspect both AP and lateral radiographs carefully AP Torus (Buckle) Fracture Failure of bone in compression Occurs in metaphysis (most porous) 19

20 Buckle Fracture Management Wrist splint x 4 weeks No need for follow up visits or X-rays Validated in multiple studies Buckle Fracture Distal Tibia Can also be managed with a splint Leg splints not always as available as wrist splints 20

21 Children vs. Adults Fracture Management Faster healing Immobilization better tolerated Greater remodeling potential Less able to use aids Fracture Assessment Inspect opposite extremity, palpate towards suspicious area Record neurovascular status when possible Get X-rays of entire bone and adjacent joint in 2 planes Consider comparison views 21

22 Common Pitfalls in Pediatric Fractures Failure to make diagnosis Failure to promptly recognize complications Failure to communicate adequately with parents Practice Changes I Hope You Make 1. X-ray entire bone and adjacent joints 2. Refer fractures needing surgery to pediatric orthopaedists/ a children s hospital 3. Consider managing selected fractures in your office 22